PassMed Flashcards

Question

Atypical antipsychotics: adverse effects

Answer 1

* weight gain * **clozapine i**s associated with **agranulocytosis** * hyperprolactinaemia Specific medications: * clozapine * **olanzapine:** higher risk of dyslipidemia and obesity * risperidone * quetiapine * amisulpride * **aripiprazole:** generally good side-effect profile, particularly for prolactin elevation

Answer 2

Agranulocytosis and neutropenia * **agranulocytosis** (1%), neutropaenia (3%) * **reduced seizure threshold** - can induce seizures in up to 3% of patients * **constipation** * myocarditis: a baseline ECG should be taken before starting treatment * hypersalivation

Answer 3

*Clozapine should be introduced if schizophrenia is not controlled despite the **sequential use of two or more antipsychotic drugs**(one of which should be a **second-generation antipsychotic drug**), each for **at least 6–8 weeks.***

Answer 4

Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment. smoking cessation causes a rise in clozapine blood levels

Answer 5

Lithium is mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys.

Answer 6

* nausea/vomiting, diarrhoea * **fine tremor** * **nephrotoxicity**: polyuria, secondary to nephrogenic diabetes insipidus * thyroid enlargement, may lead to **hypothyroidism** * ECG: **T wave flattening/inversion** * **weight gain** * idiopathic **intracranial hypertension** * **leucocytosis** * **hyperparathyroidism and resultant hypercalcaemia**

Answer 7

* when checking lithium levels, the sample should be taken 1**2 hours post-dose** * after starting lithium levels should be performed **weekly and after each dose change until concentrations are stable** * once established, lithium blood level should **'normally' be checked every 3 months** * after a _change in dose_, lithium levels should be taken a **week later and weekly until the levels are stable.** * **thyroid and renal function should be checked every 6 months** * patients should be issued with an **information booklet, alert card and record book**

Answer 8

Anxiety is a common disorder that can present in multiple ways. NICE define the central feature as an 'excessive worry about a number of different events associated with heightened tension.' Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE). Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine * Fatigue. * Trouble sleeping. * Muscle tension or muscle aches. * Trembling, feeling twitchy. * Nervousness or being easily startled. * Sweating. * Nausea, diarrhea or irritable bowel syndrome. * Irritability.

Answer 9

NICE suggest a step-wise approach: * step 1: education about GAD + active monitoring * step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups) * step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information * step 4: highly specialist input e.g. Multi agency teams Drug treatment * NICE suggest sertraline should be considered the **first-line SSRI** * if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor **(SNRI)** * examples of SNRIs include duloxetine and venlafaxine * If the person cannot tolerate SSRIs or SNRIs, consider offering **pregabalin** * interestingly for patients _under the age of 30 years_ NICE recommend you warn patients of the increased **risk of suicidal thinking and self-harm.** * **Weekly follow-up is recommended for the first month**

Answer 10

Again a stepwise approach: * step 1: recognition and diagnosis * step 2: treatment in primary care - see below * step 3: review and consideration of alternative treatments * step 4: review and referral to specialist mental health services * step 5: care in specialist mental health services Treatment in primary care * NICE recommend either cognitive behavioural therapy or drug treatment * **SSRIs** are first-line. If _contraindicated or no response after 12 weeks_ then **imipramine or clomipramine** should be offered

Answer 11

Panic disorder is a mental health condition where you have regular panic attacks. * * * Symptoms of panic disorder include feeling anxious and having sudden panic attacks. Panic disorder is usually treated with talking therapies and medicines. Things like exercise, massage, breathing techniques and yoga can also help. Panic may be triggered by misinterpretation of physical anxiety symptoms as signs of major catastrophe Safety behaviours may be adopted which reinforce beliefs (e.g. avoiding situations) CBT educates the patient on the true meaning of the symptoms (i.e. panic not perish) Helps them test whether their behaviours keep them safe and whether their beliefs are true or misinterpretations

Answer 12

Panic disorder is a mental health condition where you have regular panic attacks. * * * Symptoms of panic disorder include feeling anxious and having sudden panic attacks. Panic disorder is usually treated with talking therapies and medicines. Things like exercise, massage, breathing techniques and yoga can also help. Panic may be triggered by misinterpretation of physical anxiety symptoms as signs of major catastrophe Safety behaviours may be adopted which reinforce beliefs (e.g. avoiding situations) CBT educates the patient on the true meaning of the symptoms (i.e. panic not perish) Helps them test whether their behaviours keep them safe and whether their beliefs are true or misinterpretations

Answer 13

Patients with poor oral compliance to antipsychotics should be considered for **once monthly IM antipsychotic depot injections**

Answer 14

Factors suggesting diagnosis of depression over dementia * **short history, rapid onset** * biological symptoms e.g. **weight loss, sleep disturbance** * patient **worried about poor memory** * **reluctant to take tests, disappointed with results** * mini-mental test score: **variable** * **global memory loss** (dementia characteristically causes recent memory loss)

Answer 15

Epidemiology * 90% of patients are female * predominately affects teenage and young-adult females * prevalence of between 1:100 and 1:200 Diagnosis is now based on the DSM 5 criteria. Note that BMI and amenorrhoea are no longer specifically mentioned: **1. Restriction of energy intake relative** to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. 2. **Intense fear of** gaining weight or becoming fat, **even though underweight.** 3. Disturbance in the way in which **one's body weight or shape is experienced,** undue influence of body weight or shape on **self-evaluation, or denial** of the seriousness of the current low body weight.

Answer 16

Anorexia nervosa is associated with a number of characteristic clinical signs and physiological abnormalities which are summarised below * most things low * **G**'s and **C**'s raised: **g**rowth hormone, **g**lucose, salivary **g**lands, **c**ortisol, **c**holesterol, **c**arotinaemia Features * **reduced body mass index** * **bradycardia** * **hypotension** * **enlarged salivary glands** * **lightheaded, hair loss, dry skin** * **taking medicine to reduce hunger (appetite suppressants)** Physiological abnormalities * hypokalaemia * low FSH, LH, oestrogens and testosterone → oligomenorrhoea/amenorrhoea * raised cortisol and growth hormone * impaired glucose tolerance * hypercholesterolaemia * hypercarotinaemia * low T3

Answer 17

fear of gaining/becoming weight weight loss relative self-perception control, self-esteem, perfectionism appetite suppressants, laxatives, diuretics making themselves sick excess exercise missing meals, eating little, avoiding certain foods bowels/sex drive/weak/tired/concentration/memory/swelling sx: lightheaded, hair loss, dry skin, oligo/amenorrhoea protective factors school/work depression/OCD/substance misuse SUICIDE RISK/SELF-HARM

Answer 18

**G**'s and **C**'s raised: **g**rowth hormone, **g**lucose, salivary **g**lands, **c**ortisol, **c**holesterol, **c**arotinaemia Everything else low: * **reduced body mass index** * **bradycardia** * **hypotension** * **lightheaded, hair loss, dry skin** * **hypokalaemia** * **low FSH, LH, oestrogens and testosteron**e → oligomenorrhoea/amenorrhoea

Answer 19

Anticonvulsant Can cause toxicity at high doses Induces liver enzymes Close monitoring of carbamazepine levels is essential Check for drug interactions before prescribing * P450 enzyme inducer * dizziness and ataxia * drowsiness * headache * visual disturbances (especially **diplopia)** * **Steven-Johnson syndrome** * leucopenia and agranulocytosis * **hyponatraemia secondary t**o **syndrome of inappropriate ADH secretion** Carbamazepine is known to exhibit **autoinduction,** hence when patients start carbamazepine they may see a return of seizures after 3-4 weeks of treatment.

Answer 20

pseudohallucination is a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating. There is disagreement among specialists about not only the definition but also the role in the treatment of pseudohallucinations. Many specialists feel that it is more appropriate to think about hallucinations on a spectrum from mild sensory disturbance to hallucinations to prevent symptoms from being mistreated or misdiagnosed. An example of a pseudohallucination is a hypnagogic hallucination which occurs when transitioning from wakefulness to sleep. These are experienced vivid auditory or visual hallucinations which are fleeting in duration and may occur in anyone. These are pseudohallucinations as the affected person is able to determine that the hallucination was not real. The relevance of pseudohallucinations in practice is that patients may need reassurance that these experiences are normal and do not mean that they will develop a mental illness. Pseudohallucinations commonly occur in people who are grieving.

Answer 21

* type I disorder: mania and depression (most common) * type II disorder: hypomania and depression

Answer 22

* both terms relate to abnormally elevated mood or irritability * with mania, there is severe functional impairment or psychotic symptoms for 7 days or more * hypomania describes decreased or increased function for 4 days or more * from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania

Answer 23

there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD

Answer 24

* if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT) * if there are features of mania or severe depression then an urgent referral to the CMHT should be made

Answer 25

* sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants

Answer 26

* It advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval * the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment

Answer 27

SSRIs should be used with caution in children and adolescents. **Fluoxetine** is the drug of choice when an antidepressant is indicated

Answer 28

* **gastrointestinal symptoms** are the most common side-effect * there is an increased risk of **gastrointestinal bleeding** in patients taking SSRIs. _A proton pump inhibitor should be prescribed if a patient is also taking a NSAID_ * patients should be counselled to be vigilant for **increased anxiety and agitation after starting a SSRI** * **fluoxetine and paroxetine have a higher propensity for drug interactions**

Answer 29

* **NSAIDs:** NICE guidelines advise 'do not normally offer SSRIs', but if given _co-prescribe a proton pump inhibitor_ * **warfarin / heparin:** NICE guidelines recommend avoiding SSRIs and considering _mirtazapine (NaSSA)_ * **aspirin:** see above * **triptans** - increased risk of _serotonin syndrome_ * **monoamine oxidase inhibitors (MAOIs)** - increased risk of serotonin syndrome

Answer 30

4 weeks 6 months

Answer 31

increased mood change restlessness difficulty sleeping unsteadiness sweating GI symptoms: pain, cramping, diarrhoea, vomiting paraesthesia

Answer 32

Paroxetine

Answer 33

BNF says to weigh up benefits and risk when deciding whether to use in pregnancy. - Use during the _first trimester_ gives a small increased risk of **congenital heart defects** - Use during the _third trimester_ can result in **persistent pulmonary hypertension of the newborn** * *_- Paroxetine_** has an increased risk of congenital malformations, particularly in the first trimester

Answer 34

intentional production of physical or psychological symptoms

Answer 35

Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

Answer 36

Multiple physical symptoms present for at least 2 years patient refuses to accept reassurance or negative test results

Answer 37

Persistent belief in the presence of an underlying SERIOUS DISEASE, e.g. cancer patient again refuses to accept reassurance or negative test results

Answer 38

loss of motor or sensory function may be caused by stress patient doesn't consciously feign the symptoms (factitious disorder) or seek maternal gain (malingering) patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

Answer 39

‘separating off’ certain memories from normal consciousness in contrast to conversion disorder involves psychiatric symptoms e.g. amnesia, fugue, stupor DID is the new term for multiple personality disorder as is the most severe form of dissociative disorder

Answer 40

The strongest risk factor for developing a psychotic disorder (including schizophrenia) is family history. Having a parent with schizophrenia leads to a relative risk (RR) of 7.5. Risk of developing schizophrenia * monozygotic twin has schizophrenia = 50% * parent has schizophrenia = 10-15% * sibling has schizophrenia = 10% * no relatives with schizophrenia = 1% Other selected risk factors for psychotic disorders include: * Black Caribbean ethnicity - RR 5.4 * Migration - RR 2.9 * Urban environment- RR 2.4 * Cannabis use - RR 1.4

Answer 41

Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term memory loss - this is called pseudodementia

Answer 42

* short history, rapid onset * biological symptoms e.g. weight loss, sleep disturbance * patient worried about poor memory * reluctant to take tests, disappointed with results * mini-mental test score: variable * global memory loss (dementia characteristically causes recent memory loss)

Answer 43

* Efforts to avoid real or imagined abandonment * Unstable interpersonal relationships which alternate between idealization and devaluation * Unstable self image * Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse) * Recurrent suicidal behaviour * Affective instability * Chronic feelings of emptiness * Difficulty controlling temper * Quasi psychotic thoughts feelings of emptiness, unstable relationships, and an unpredictable affect with threats/acts of self-harm.

Answer 44

Sx present for **more than a month** following a traumatic event * **re-experiencing** = flashbacks, nightmares, repetitive and sdistressing intrusive images * **avoidance** = avoiding people, situations or circumstances resembling or associated with the event * **hyperarousal** = hyper vigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentration * **emotional numbing** = lack of ability to experience feelings, feeling detached Others = depression, drug or alcohol misuse, anger, unexplained physical symptoms

Answer 45

Acute stress disorder is less than 4 weeks

Answer 46

Aged 35-54 Being divorced or separated Living alone Being a lone parent

Answer 47

Aged 16-24 Being married or cohabiting

Answer 48

deliberate self-harm is more common in females completed suicide is more common in males.

Answer 49

* male * hx of deliberate self-harm * alcohol or drug misuse * hx of mental illness (depression, schizophrenia) * hx of chronic disease * advancing age * unemployment or social isolation/living alone * being unmarried, divorced or widowed If attempted suicide → risk of completed suicide: * efforts to avoid discovery * planning * leaving a written note * final acts such as sorting out finances * violent method

Answer 50

SCHNEIDER’S FIRST RANK SYMPTOMS * **Auditory hallucinations** = 2 or more voices discussing patient in third person, thought echo, voices commenting on the patient’s behaviour * **Thought disorder** = insertion, withdrawal, broadcasting * **Passivity phenomena** = bodily sensations being controlled by external influence, actions/impulses/feelings – experienced which are imposed on the individual or influences by others * **Delusional perceptions** = two-stage process, the traffic light is green therefore I am the King Other features: * Impaired insight * Incongruity/blunting of affect (inappropriate emotion for circumstances) * Decreased speech * Neologisms: made-up words * Catatonia * Negative symptoms: incongruity/blunting of affect, anhedonia, alogia, avolition

Answer 51

SCHIZOPHRENIA sleep disturbances such as insomnia often reported by patients as their symptoms of schizophrenia develop

Answer 52

HbA1C = diabetes control (hypoglycaemia/hyperglycaemia) CXR = chest infection **CT head** = for elderly patients with _new sudden onset psychosis_ to rUle out an organic cause (e.g. brain tumour, stroke or cos INFECTION)

Answer 53

mild (**shivering and diarrhea**) to severe (muscle rigidity, fever and seizures)

Answer 54

large increase in appetite → weight gain drowsiness

Answer 55

Class 1 (hypongonadtropic hypogonadal anovulation) = hypothalamic amenorrhoea Class 2 (normogonadotropic normoestrogenic anovulation) = PCOS (80% cases) Class 3 (hypergonadotropic hypoestrogenic anovulation) = POI → ovulation induction unsuccessful → IVF with done oocytes to conceive required

Answer 56

Exercise and weight loss * 1st line for PCOS (overweight/obese women) Letrozole * 1st line for PCOS over clomiphene citrate. * Aromatase inhibitor → reduce -ve feedback caused by oestrogen to pituitary gland → increase in FSH for follicular development * higher rate of mono-follicular development * side effects = fatigue, dizziness Clomiphene citrate * SERM → acts on hypothalamus → increase GnRH → increase FSH + LH → follicular development * 2nd line PCOS * side effects = hot flushes, abdominal distension and pain, N+V Gonadotropin therapy * for class 1 ovulatory dysfunction * risk of multi-follicular development and subsequent multiple pregnancy much higher * higher risk of OHSS * GnRH IV infusion pump → endogenous FSH + LH production → follicular development

Answer 57

r. With antidepressants and ECT, you do not suddenly stop them when the patient commences ECT treatment. The recommended regime is to safely reduce them to the minimum dose. You may actually add an increased dose of antidepressant towards the end of the ECT course.

Answer 58

Mirtazapine is an effective antidepressant which is an alpha-2 receptor antagonist, but is often not tolerated by patients as it commonly causes increased appetite and sedation.

Answer 59

* rasagiline * selegiline * isocarboxazid * phenelzine tyramine cheese reaction = high tyramine foods (e.g. cheese) → hypertensive crisis Increased risk of serotonin syndrome

Answer 60

Post-concussion syndrome is seen after even minor head trauma Typical features include * headache * fatigue * anxiety/depression * dizziness

Answer 61

characterised by negative symptoms including blunting of affect, alogia (poverty of speech) and avolition (poor motivation), echolalia

Answer 62

Echolalia is the repetition of someone else's speech including the questions being asked. It is a feature of schizophrenia, typically catatonic schizophrenia

Answer 63

* **Hypersensitivity and an unforgiving** attitude when insulted * Unwarranted tendency to **questions the loyalty** of friends * **Reluctance to confide** in others * Preoccupation with **conspirational beliefs and hidden meaning** * Unwarranted tendency to **perceive attacks on their character**

Answer 64

* indifference to praise and criticism * preference for solitary activities * lack of interest in sexual interactions * lack of desire for companionship * emotional coldness * few interests * few friends or confidants other than family

Answer 65

* Ideas of reference (differ from delusions in that some insight is retained) * **Odd beliefs and magical thinking** * Unusual perceptual disturbances * Paranoid ideation and suspiciousness * **Odd, eccentric behaviour** * **Lack of close friends** other than family members * Inappropriate affect * **Odd speech without being incoherent**

Answer 66

* **Failure to conform** to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest; * **More common in men;** * **Deception,** as indicated by **repeatedly lying**, use of aliases, or conning others for **personal profit or pleasure;** * **Impulsiveness or failure to plan ahead;** * **Irritability and aggressiveness,** as indicated by repeated physical fights or assaults; * Reckless disregard for the safety of self or others; * Consistent **irresponsibility,** as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations; * **Lack of remorse,** as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Answer 67

* efforts to avoid real or imagined abandonment * unstable interpersonal relationships which alternate between idealisation and devaluation * unstable self-image * impulsivity in potentially self damaging area (e.g. spending, sex, substance abuse) * recurrent suicidal behaviour * affective instability * chronic feelings of emptiness * difficulty controlling temper * quasi psychotic thoughts Mx: DBT * Understand and accept your difficult feelings * Learn skills to manage them * Become able to make positive changes in your life

Answer 68

* Inappropriate sexual seductiveness * Need to be the centre of attention * Rapidly shifting and shallow expression of emotions * Suggestibility * Physical appearance used for attention seeking purposes * Impressionistic speech lacking detail * Self dramatization * Relationships considered to be more intimate than they are

Answer 69

* Grandiose sense of self importance * Preoccupation with fantasies of unlimited success, power, or beauty * Sense of entitlement * Taking advantage of others to achieve own needs * Lack of empathy * Excessive need for admiration * Chronic envy * Arrogant and haughty attitude

Answer 70

* Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone * Demonstrates perfectionism that hampers with completing tasks * Is extremely dedicated to work and efficiency to the elimination of spare time activities * Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values * Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning * Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things * Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness

Answer 71

* Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection. * Unwillingness to be involved unless certain of being liked * Preoccupied with ideas that they are being criticised or rejected in social situations * Restraint in intimate relationships due to the fear of being ridiculed * Reluctance to take personal risks due to fears of embarrassment * Views self as inept and inferior to others * Social isolation accompanied by a craving for social contact

Answer 72

* Difficulty making everyday decisions without excessive reassurance from others * Need for others to assume responsibility for major areas of their life * Difficulty in expressing disagreement with others due to fears of losing support * Lack of initiative * Unrealistic fears of being left to care for themselves * Urgent search for another relationship as a source of care and support when a close relationship ends * Extensive efforts to obtain support from others * Unrealistic feelings that they cannot care for themselves

Answer 73

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

Answer 74

Othello syndrome is **pathological jealousy,** most commonly the belief that their partner is **not faithful**, and can be **isolated delusion** or **secondary to an affective state**, schizophrenia or a personality disorder. The patient often obsessively **searches for evidence**, but is not satisfied when none is found. Can then result in **violent behaviour.**

Answer 75

Fluoxetine

Answer 76

* 24-30- no cognitive impairment * 18-23- mild cognitive impairment * 0-17- Severe cognitive impairment

Answer 77

As a rule of thumb, when performing a mini mental state examination on a patient with depression they will answer with 'I don't know', whereas patients with Alzheimer's will try their best to answer your questions, but answer incorrectly. Score more variable in depression

Answer 78

hypothyroidism → weight gain and tiredness

Answer 79

Neuroleptic malignant syndrome (NMS) is **a rare reaction to antipsychotic drugs that treat schizophrenia, bipolar disorder, and other mental health conditions**. The condition is serious, but it's treatable 4 features: * **hyperthermia** * **rigidity** * **autonomic instability** * **altered mental state** Ix = **CPK** (baseline, repeat if there are signs and symptoms of NMS)

Answer 80

Blood glucose (fasting and HbA1c) Blood lipids (fasting) FBC = blood dyscrasias LFTs = liver toxicity U+Es and renal function = renal toxicity TFTs = only for BPAD CPK = for NMS (just baseline) Prolactin = just baseline ECG = annually BP and pulse Weight + BMI Smoking Status = e.g. for clozapine Side effects

Answer 81

cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates) QRISK3 Scoring

Answer 82

* chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors * alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Answer 83

Symptoms start at **6-12 hours**: tremor, sweating, tachycardia, anxiety peak incidence of _seizures_ at **36 hours** peak incidence of _delirium tremens_ at **48-72 hours:** coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Answer 84

* atients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be **admitted to hospital for monitoring until withdrawals stabilised** * _first-line:_ **long-acting benzodiazepines e.g. chlordiazepoxide or diazepam**. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol * carbamazepine also effective in treatment of alcohol withdrawal * phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures **regular high strength IM B vitamin replacement =** prophylaxis for Wernicke's Encephalopathy

Answer 85

Wernicke's encephalopathy is a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics. Rarer causes include: persistent vomiting, stomach cancer, dietary deficiency. A _classic triad_ of **ophthalmoplegia/nystagmus, ataxia and confusion** may occur. In Wernicke's encephalopathy **petechial haemorrhages** occur in a variety of structures in the brain including the mamillary bodies and ventricle walls. Ix = **decreased red cell transketolase, MRI** Tx = urgent replacement of **thiamine**

Answer 86

Overview * marked memory disorder often seen in alcoholics * thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus * in often follows on from untreated Wernicke's encephalopathy Features * anterograde amnesia: inability to acquire new memories * retrograde amnesia * confabulation

Answer 87

If not treated Korsakoff's syndrome may develop as well. This is termed Wernicke-Korsakoff syndrome and is characterised by the addition of antero- and retrograde amnesia and confabulation in addition to the above symptoms. ››

Answer 88

lipids and blood glucose CK is done if NMS is suspected

Answer 89

emergence of any movement disorders

Answer 90

olanzapine aripripazole

Answer 91

Schizophrenia is an illness that affects how someone thinks, feels and behaves, and can often cause someone to lose touch with reality 1% of population Age of onset 16-35 Prodrome phase = social withdrawal, nervousness, anxiety, depression, difficulty concentrating, excessive worrying GENETICS

Answer 92

Mesolimbic pathway overactivity = positive symptoms Mesocortical pathway = negative and cognitive symptoms Tuberoinfundibular pathway = hyperprolactinaemia Nigrostriatal = EPSE

Answer 93

social withdrawal, nervousness, anxiety, depression, difficulty concentrating, excessive worrying

Answer 94

Do you have **new feelings and thoughts which you have never had before,** which make you disturbed or anxious? Do you feel able to **look after your baby adequately**? Sometimes people feel like they are **incompetent,** as though they can't cope, or estranged from your baby, does this happen to you? Are these feelings persistent? Are you experiencing thoughts of **suicide or harming yourself** in violent ways? Sometimes people have unpleasant thoughts about **harming their baby,** does that happen to you?

Answer 95

Olanzapine and Fluoxetine Li not totally contra-indicated NOT NaVal

Answer 96

1 month, Sx’s present most of the time * **POSITIVE** = passivity (external influence), hallucinations, delusions, thought disorder (chaotic thinking, tangentiality, flight of ideas, word salad) * Catatonia (lack of movement, communication, agitation, confusion, restlessness) disorganised behaviours) * **NEGATIVE** = poor volition, poor cognition, blunted affect

Answer 97

avoidant-restrictive food intake disorder = is **an eating disorder similar to anorexia**. Both conditions involve intense restrictions on the amount of food and types of foods you eat. But unlike anorexia, people with ARFID aren't worried about their body image, shape, or size Other Specified Feeding or Eating Disorder Binge Eating Disorder = NO compensatory mechanism

Answer 98

Protective factors = peers partner, work, supportive family Stressors = school, work, peers, unsupportive family

Answer 99

Fluoxetine + CBT for ED

Answer 100

HTT IS THE CRISIS TEAM

Answer 101

* chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors * alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Answer 102

* symptoms start at **6-12 hours**: tremor, sweating, tachycardia, anxiety * peak incidence of _seizures_ at **36 hours** * peak incidence of delirium tremens is at **48-72 hours:** coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Answer 103

* **AUDIT** – alcohol use disorders identification test (\>15 requires comprehensive assessment) * **SADQ** – severity of dependence * **CIWA-Ar** – clinical institute withdrawal assessment of alcohol scale (for severity of withdrawal) * **APQ** – alcohol problems questionnaire (assess the nature and extent of the problems arising from alcohol misuse)

Answer 104

Bloods = FBC, LFT, B12/folate, U+Es, clotting screen, glucose Blood alcohol level or breathalyser UDS Rating scale (e.g. AUDIT, CIWA-Ar, APQ) Severity of Alcohol Dependence Questionnaire (SADQ)

Answer 105

irreversible inhibitor of acetaldehyde dehydrogenase. This inhibition causes the **buildup of acetaldehyde.** The build-up of acetaldehyde within **twenty to thirty minutes** of alcohol consumption results in unpleasant symptoms, including **facial flushing and nausea and vomiting.** The reaction can be life-threatening, so disulfiram is _not recommended for_ patients with underlying frailty, neurological, cardiac or hepatic conditions. Disulfiram is taken **once daily** and its **effects last seven days,** working as a **deterrent to prevent alcohol relapse.**

Answer 106

taken **three times a day** and has shown to be effective in **preventing alcohol relapse** in combination with psychological support following detoxification in alcohol dependence syndrome. It is typically described as an _'anti-craving' medication_ and the underlying mechanism of action remains unclear. Acamprosate has a **minimal side-effect and risk profile** and is safe in combination with alcohol. another anti-craving drug is **_NALTREXONE_**

Answer 107

**mixed opioid agonist/antagonist**. It is typically given as a _sublingual tablet_ and provides an alternative opiate **replacement therapy to methadone.** Patient's often describe buprenorphine as **less sedating,** which can be a benefit or drawback depending on the context and patient. Prescribers must also be aware that because of the opioid antagonist properties of methadone it **can render regularly prescribed analgesia, such as co-codamol, ineffective.**

Answer 108

**Chlordiazepoxide** is a benzodiazepine often used as part of a reducing regime during alcohol detoxification. **Diazepam** is also a benzodiazepine. Diazepam is typically used as an anxiolytic but is also used as part of a reducing regime during alcohol detoxification. **Ondansetron** is a _5-HT3 receptor antagonist_ used as an _anti-emetic._ Ondansetron is often used to manage these symptoms during detoxification from alcohol or opiates

Answer 109

Family/carers: * offer carers assessment if necessary * consider offer guided self-help for families and provide resources about support groups * consider offering **family meetings**, usually _5 weekly_ meetings **Abstinence** best treatment goal = if co-morbid mental health issues don't improve within _3-4 wk_ abstinence, consider referring for specific treatment Principles of interventions * **motivation interview** * interventions to promote abstinence as part of intensive structured community-based intervention * _homeless_ = **residential rehabilitation** services (max **3 months)** * **routinely monitor** outcomes * **Info** = AA, SMART Recovery, Change Grow Live (CGL) * **Care coordination** * **Case management** = individualised care plan

Answer 110

**Psych intervention** (e.g. CBT, behavioural therapy, social network and environment-based) focuses on alcohol-related cognitions → weekly 1 hour sessions for 12 weeks **Behavioural couples therapy** if regular partner present If not response to above/pharm tx requested: psych therapy with * **acamprosate (anti-craving)** * **naltrexone**

Answer 111

**Pabrinex** if at risk of WE Withdrawal sx worst within 48 hours, takes 3-7 days after last drink to completely resolve _If \>15 units/day or \>20 on AUDIT,_ consider offering: * **community-based assisted withdrawal (BEST OPTION)** = via CGL, 2-4 meetings in first week, if complex then 4-7 days per week over 3 wk period * **management in specialist alcohol services** if there are safety concerns

Answer 112

* 30 units+ a day * 30+ on SADQ * hx of epilepsy, delirium tremens or withdrawal-related seizures * need concurrent withdrawal of alcohol and BDZPs * significant psychiatric comorbidity or significant LD * lower threshold for inpatient tx in vulnerable groups (e.g. homeless, older people) * _children (10-17)_ → should receive **FAMILY THERAPY** for about **3 months**

Answer 113

dyslipidaemia, weight gain, dysglycaemia, DM, increased glucose tolerance

Answer 114

* 0-4 no depression identified * 5-9 mild depression * 10-14 moderate depression * 15-19 moderately severe depression * 20-27 severe depression

Answer 115

use **LORAZEPAM**

Answer 116

relatively rare condition where a patient has a fixed, false belief (delusion) that they are infested by 'bugs' e.g. worms, parasites, mites, bacteria, fungus. This may occur in conjunction with other psychiatric conditions or may present by itself, with patients often otherwise quite functional despite the delusion.

Answer 117

this is a delusional misidentification syndrome whereby the patient believes that someone significant in their life, such as a spouse or a friend, has been **replaced** by an identical imposter.

Answer 118

This is another delusional misidentification syndrome where the patient believes that **multiple people are in fact all the same person,** who is constantly changing their appearance.

Answer 119

BDZPs and ECT

Answer 120

post-concussive syndrome symptoms last **more than three months after the initial injury.** They are often **non-specific neurological symptoms.** The initial injury is often trivial and can be overlooked by patients. This patient has a history of contact sports which he states included trauma. Post-concussion syndrome is seen after even minor head trauma Typical features include * headache * fatigue * anxiety/depression * dizziness

Answer 121

LONG ACTING (e.g. chlordiazepoxide) over short acting (e.g. lorazepam) as long acting has longer half life so more likely to prevent seizures

Answer 122

U - U waves No Pot - No potassium No T - no T waves Long PR - long PR interval Long QT - long QT interval tall p wave

Answer 123

* typically develops in the **late teen years** * lifetime prevalence: **2%**

Answer 124

* type I disorder: mania and depression (most common) * type II disorder: hypomania and depression

Answer 125

strong FHx gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant

Answer 126

more than 6 months following bereavement

Answer 127

Pseudohallucinations = alse sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating.

Answer 128

* drowsiness * dry mouth * blurred vision * constipation * urinary retention * lengthening of QT interval

Answer 129

* **low-dose amitriptyline** is commonly used in the management of _neuropathic pain_ and the _prophylaxis of headache_ (both tension and migraine) * **lofepramine** has a lower incidence of toxicity in overdose * **amitriptyline and dosulepin** (dothiepin) are considered the _most dangerous in overdose_

Answer 130

Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures Features * **paralysis** - this occurs after waking up or shortly before falling asleep * **hallucinations** - images or speaking that appear during the paralysis Management * if troublesome **clonazepam** may be used

Answer 131

enhance the **inhibitory NT GABA** by increasing **frequency** of chloride channels * sedation * hypnotic * anxiolytic * anticonvulsant * muscle relaxant

Answer 132

**2-4 weeks** as patients commonly develop tolerance and dependence to them

Answer 133

The dose should be withdrawn in steps of about **1/8** (range 1/10 to 1/4) **of the daily dose every fortnight.** A suggested protocol for patients experiencing difficulty is given: * switch patients to the equivalent dose of **diazepam** * reduce dose of diazepam **every 2-3 weeks in steps of 2 or 2.5 mg** * time needed for withdrawal can vary from **4 weeks to a year or more**

Answer 134

his may occur up to 3 weeks after stopping a long-acting drug. Features include: * insomnia * irritability * anxiety * tremor * loss of appetite * tinnitus * perspiration * perceptual disturbances * seizures

Answer 135

**Circumstantiality** describes a situation in which a patient may reply to a question with an irrelevant, detailed answer, but will eventually return to the point. **Tangentiality** describes speech which wanders from a topic, without returning to it. **Flight of ideas,** a feature of mania, is thought disorder where there are leaps from one topic to another but with discernible links between them. **Knight's move thinking** is a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia. **Perseveration** describes persistent repetition of speech on the same subject, despite attempting to change the subject. **Word salad** is completely incoherent speech where real words are strung together into nonsense sentences. **Echolalia** is the repetition of someone else's speech, including the question that was asked. **Neologisms** are new word formations, which might include the combining of two words. **Clang associations** are when ideas are related to each other only by the fact they sound similar or rhyme.

Answer 136

\<4 weeks features * intrusive thoughts e.g. flashbacks, nightmares * dissociation e.g. ‘being in a daze’, time slowing * negative mood * avoidance * arousal e.g. hyper vigilance, sleep disturbance

Answer 137

TF-CBT BDZPs for acute sx (e.g. agitation, sleep disturbance) use with caution

Answer 138

propanolol

Answer 139

* **S**omatisation = **S**ymptoms * hypo**C**hondria (illness anxiety disorder)= **C**ancer

Answer 140

* symptoms: **6-12 hours** * seizures: **36 hours** * delirium tremens: **72 hours**

Answer 141

HTN (measure BP prior and dose titration)

Answer 142

U+Es for hyponatraemia

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